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Cardiac Emergencies Flashcards

1
Q

Rapid A-Fib & A-Flutter

A

Ventricular Rates Greater than 150 BPM

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2
Q

Stable A-Fib & A Flutter Treatment

A
  • Cardizem 10mg IV/IO Over 2 mins
    If no response in 5 minutes 2nd 15mg
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3
Q

Unstable A-Fib & A- Flutter (Hypotension)

A
  • Normal Saline 1L x1
    If pt remains hypotensive:
  • Push-dose Epi
    If Pt Becomes Normotensive Switch to Cardizem
    Cardizem Induced Hypotension:
    Calcium chloride
    500mg IV/IO Over 2 Minutes
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4
Q

PEDIATRIC: Rapid A-Fib & A-Flutter

A

Call For Orders

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5
Q

Adult Bradycardia < 50 Stable and Unstabel

A

Stable
* Monitor & Transport
Unstable
* Atropine 0.5mg IV/IO repeat every 3 Minutes Max 3mg

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6
Q

IF PATIENT DETERIORATES OR HYPOTENSION PERSISTS AFTER 2 DOSES OF ATROPINE

A

TRANSCUTANEOUS PACING:
* Initial rate of 60 beats per minute and increase milliamps until capture is gained
* Increase the rate as needed until the patient is hemodynamically stable

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7
Q

SEDATION FOR TRANSCUTANEOUS PACING

A

ETOMIDATE:
6mg IV/IO
May repeat 1x prn

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8
Q

IF UNABLE TO ESTABLISH VASCULAR ACCESS AND PATIENT BECOMES NORMOTENSIVE SECONDARY TO TRANSCUTANEOUS PACING

A

VERSED:
5mg IN/IM
May repeat 1x prn, in 5 minutes

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9
Q

IF PATIENT REMAINS HYPOTENSIVE AFTER ATROPINE OR TRANSCUTANEOUS PACING

A
  • PUSH-DOSE PRESSOR EPINEPHRINE
    May repeat x2
    Max total dose 300mcg (30 mL)
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10
Q

BRADYCARDIA IN THE PRESENCE OF A MI

A

Go directly to transcutaneous pacing for unstable bradycardia in the presence of a myocardial infarction as ATROPINE increases myocardial ischemia and may increase the size of the infarct.

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11
Q

PEDIATRIC: STABLE BRADYCARDIA

A
  • OXYGENATION:
    Ensure adequate oxygenation first, as hypoxia is most likely to be the cause of the bradycardia
  • Monitor and transport
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12
Q

PEDIATRIC: UNSTABLE (AMS AND AGE-APPROPRIATE HYPOTENSION)

A
  • VENTILATION:
  • Neonates:
    1 breath every 3 seconds for at least 30 seconds
  • Infants/Children:
    1 breath every 3 seconds for at least 1 minute
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13
Q

PEDIATRIC: (IF PATIENT REMAINS UNSTABLE AFTER VENTILATIONS AND THE HEART RATE REMAINS BELOW 60 BEATS PER MINUTE)

A

220 compressions every 2 minutes

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14
Q

PEDIATRIC: IF NO RESPONSE TO OXYGENATION, VENTILATION, AND CHEST COMPRESSIONS

A

PUSH-DOSE EPI

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15
Q

PEDIATRIC: IF BRADYCARDIC AND HYPOTENSION PERSISTS AFTER INITIAL DOSE OF EPINEPHRINE

A

TRANSCUTANEOUS PACING:
* Initial rate of 80 beats per minute and increase milliamps until capture is gained
* Increase the rate as needed until the patient is hemodynamically stable

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16
Q

PEDIATRIC: SEDATION FOR TRANSCUTANEOUS PACING

A

0.1mg/kg IV/IO, over 30 seconds, max single dose 6mg
May repeat 1x prn

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17
Q

PEDIATRIC: IF UNABLE TO ESTABLISH VASCULAR ACCESS AND PATIENT BECOMES NORMOTENSIVE SECONDARY TO TRANSCUTANEOUS PACING

A
  • VERSED
    0.2 mg/kg IN/IM, max single dose of 5mg
    May repeat either route 1x prn, in 5 minutes
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18
Q

Cardiogenic Shock

A
  • A condition in which the heart suddenly can’t pump enough blood to meet the body’s needs
  • Most often caused by a severe heart attack
  • Rare, but often fatal if not treated immediately
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19
Q

PULMONARY EDEMA WITH HYPOTENSION ADULT AND PEDIATRIC

A
  • PUSH-DOSE PRESSOR EPINEPHRINE
  • NORMAL SALINE 1L
    Peds: 20mL/kg
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20
Q

ADULT CHEST PAIN

A
  • Obtain 12 and 15 lead ECGs and leave cables connected
  • The right hand and right wrist should be avoided for vascular access if at all possible. These sites may be utilized for cardiac catheterization.
  • The right AC and anywhere on the left is acceptable
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21
Q

ADULT CHEST PAIN TREATMENT

A
  • ASPIRIN:
    324 mg
  • FENTANYL:
    100mcg IV/IO/IN/IM (2mL)
    May repeat 2x prn, in 5 minute intervals
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22
Q

CHEST PAIN: IF PAIN/DISCOMFORT PERSISTS AFTER MAXIMUM FENTANYL ADMINISTRATION OR DRUG SEEKING BEHAVIOR IS SUSPECTED

A
  • NITROGLYCERIN:
  • 0.4mg SL
  • May repeat 2x prn, in 5 minute intervals
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23
Q

PEDIATRIC CHEST PAIN

A

Call for orders

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24
Q

STEMI SYMPTOMS

A
  • Discomfort of the chest, arm, neck, back, shoulder or jaw
  • Syncope or near syncope
  • General weakness
  • Unexplained diaphoresis
  • SOB
  • Nausea/Vomitin
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25
STEMI ALERT CRITERIA
* ST-Segment Elevation in 2 or more contiguous leads: * Convex (frown face) (Sad Face) 2mm or greater in V2 and V3 * 1mm or greater in all other leads * Concave (smiley face) 2mm or greater in any lead - All STEMI Alerts shall be transported as priority 2
26
STEMI ALERT DISQUALIFIERS
* Left Bundle Branch Block (QRS complexes > 0.12) * Pacemaker with QRS complexes > 0.12 * Left Ventricular Hypertrophy (LVH) * Early repolarization * < 2mm of elevation with a concave (smiley face) morphology * Patient presentations indicative of myocardial ischemia that DO NOT meet “STEMI Alert Criteria” should still be transported Priority 2 to a STEMI facilit
27
CHEST PAIN: RIGHT VENTRICULAR FAILURE: POSITIVE V4R, CLEAR LUNG SOUNDS WITH HYPOTENSION
NORMAL SALINE: * 1L IV/IO, titrate to desired effect WITH OR WITHOUT CHEST PAIN * ASPIRIN
28
CHF (Pulmonary Edema) SIGNS AND SYMPTOMS
* Hypertension * Tachycardia * Orthopnea (SOB while lying flat) * Rales * Pedal Edema
29
CHF (Pulmonary Edema) TREATMENT
* NITROGLYCERIN: 0.8mg SL (2 stacked sprays) May repeat with 0.4mg SL (1 spray), 2x prn, every 5 minutes * CPAP - (10 cm H₂O)
30
PEDIATRIC: CHF (Pulmonary Edema)
Call for orders
31
If patient is febrile or from a nursing home and pneumonia is suspected
Withhold nitrates
32
ST VS SVT
* SVT will generally have no discernible P-waves or there may be P-waves just after the QRS complex * History that favors ST (e.g., dehydration, fever, pain, anxiety, physical activity, exertional heat stroke, etc.) * Vagal maneuvers may gently slow down ST but will either not affect SVT OR abruptly break the SVT (SVT shouldn't gently terminate) * Adult: QRS width < 0.12 (3 small boxes) Rate: > 150 beats per minute after ST has been ruled out * Pediatric: QRS width < 0.09 (2 small boxes) Rate: SVT in pediatrics is considered > 180 beats per minute * SVT in infants: Considered > 220 beats per minute
33
SVT: STABLE (AAOX4 WITH OR WITHOUT HYPOTENSION)
* VAGAL MANEUVERS * ADENOSINE: 12mg rapid IV/IO, with a 20mL NORMAL SALINE flush * Print ECG during administration
34
SVT: IF SVT FAILS TO CONVERT/ADENOSINE IS CONTRAINDICATED OR PATIENT HAS HISTORY OF ATRIAL DYSRHYTHMIAS
* CARDIZEM: * 10mg IV/IO, over 2 minutes If no response in 5 minutes, repeat with 15 mg IV/IO, over 2 minutes
35
CARDIZEM-INDUCED HYPOTENSION
* NORMAL SALINE: 1L IV/IO, titrate to desired effect * CALCIUM CHLORIDE: 500mg IV/IO, over 2 minutes
36
SVT: UNSTABLE (ALTERED MENTAL STATUS WITH OR WITHOUT HYPOTENSION)
* ETOMIDATE: 6mg IV/IO May repeat 1x prn * SYNCHRONIZED CARDIOVERSION: 120j, 150j, 200j Repeat 360j until successfully converted
37
PEDIATRIC SVT TREATMENT
* VAGAL MANEUVERS * ADENOSINE: 0.2mg/kg rapid IV/IO, with a simultaneous 10mL NORMAL SALINE flush Max single dose 12mg If no change in 1 minute: * Repeat 0.2mg/kg rapid IV/IO, with a simultaneous 10mL NORMAL * Print ECG during administration
38
PEDIATRIC SVT: UNSTABLE (ALTERED MENTAL STATUS WITH OR WITHOUT AGE-APPROPRIATE HYPOTENSION)
* ETOMIDATE (consider for sedation): 0.1mg/kg IV/IO, over 30 seconds, max single dose 6mg May repeat 1x prn, max total dose 12mg * SYNCHRONIZED CARDIOVERSION: 0.5j/kg If not effective, increase to 2j/kg * Repeat 2j/kg until successfully converted
39
VENTRICULAR TACHYCARDIA (V-TACH)
* V-TACH has no discernible P waves * Precordial concordance: All chest leads point in the same direction (either positive OR negative) * Negative Lead V6 * Backward frontal plane axis: II, III, and aVF are negative; aVL and aVR are positive * Presence of capture beats or fusion beats (sinus beats that interrupt the WCT) * Rate usually > 120 beats per minute * QRS width > 0.12 (3 small boxes)
40
STABLE WIDE COMPLEX TACHYCARDIA (WCT) TREATMENT
* AMIODARONE INFUSION: Dilute 150mg of in a 50mL bag of D5W Administer over 10 minutes IV/IO by utilizing a 10 gtt set delivering 1 gtt/sec * Administer all 150mg, even if the WCT terminates May repeat 1x prn
41
WCT: UNSTABLE WCT (ANY AMIODARONE CONTRAINDICATION)
* ETOMIDATE: 6mg IV/IO May repeat 1x prn * SYNCHRONIZED CARDIOVERSION: 120j, 150j, 200j Repeat 200j until successfully converted * If a WCT converts with cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed
42
WCT PATIENTS WHO CONVERT AFTER CARDIOVERSION
*12-lead and 15-lead * Rule out any contraindications to AMIODARONE * AMIODARONE INFUSION: If not already administer Only for patients who convert after (any of the following): * 2 cardioversions by Fire Department * 2 or more shocks by their Implantable Cardioverter (ICD) * DO NOT administer amiodarone if the patient has already received amiodarone
43
REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT)
* RRWCT in adult and pediatric patients has a QRS width ≥ 0.20 (5 small boxes or 1 large box) * Rate usually < 120 beats per
44
STABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT)
* CALCIUM CHLORIDE:1g IV/IO, over 2 minutes * SODIUM BICARBONATE: 100 mEq, IV/IO, over 2 minutes
45
RRWCT WITH HYPOTENSION SHALL BE TREATED AS UNSTABLE
* ETOMIDATE (consider for sedation): 6mg IV/IO May repeat 1x prn * SYNCHRONIZED CARDIOVERSION: 120j, 150j, 200j * If a RRWCT converts with cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed
46
IF UNSTABLE RRWCT FAILS TO CONVERT AFTER CARDIOVERSION OF 200J
* CALCIUM CHLORIDE: as noted above * SODIUM BICARBONATE: as noted above * SYNCHRONIZED CARDIOVERSION: * 200j every 2 minutes prn
47
PEDIATRIC: STABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA
* CALCIUM CHLORIDE: 20mg/kg IV/IO, over 2 minutes * SODIUM BICARBONATE: 1mEq/kg IV/IO, over 2 minutes Max single dose 50mEq May repeat 1x prn, in 5 minutes. Max total dose 100mEq
48
PEDIATRIC: UNSTABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA (AGE-APPROPRIATE HYPOTENSION)
* ETOMIDATE: * 0.1mg/kg IV/IO, over 30 seconds, max single dose 6mg * May repeat 1x prn * SYNCHRONIZED CARDIOVERSION: * 0.5j/kg * If no response, increase to 2j/kg * If a WCT converts with cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed * Contraindications - WCTs that are irregularly-irregular
49
PEDIATRIC: IF UNSTABLE RRWCT FAILS TO CONVERT AFTER CARDIOVERSION
* CALCIUM CHLORIDE: 20mg/kg * SODIUM BICARBONATE: 1mEq/kg * SYNCHRONIZED CARDIOVERSION: 2j/kg every 2 minutes prn
50
Polymorphic V-Tach/ Torsades de Pointes: Risk factors
* Congenital long QT syndrome * Female gender * Renal/liver failure * Medications that cause QT interval prolongation (e.g., anti-dysrhythmics, calcium channel blockers, psychiatric drugs, antihistamines)
51
STABLE POLYMORPHIC V-TACH
* MAGNESIUM SULFATE: * Dilute: 2g of magnesium sulfate in a 50mL bag of D5W Administer IV/IO utilizing a 60 gtt set, run wide open
52
UNSTABLE POLYMORPHIC V-TACH (HYPOTENSION)
* ETOMIDATE (consider for sedation): * 6mg IV/IO * May repeat 1x prn * DEFIBRILLATION: * 120j, 150j, 200j * If a PVT converts with defibrillation and later returns to a PVT, use the last successful energy setting and increase as needed
53
IF UNSTABLE POLYMORPHIC V-TACH CONVERTS AFTER DEFIBRILLATION AND MAGNESIUM SULFATE HAS NOT ALREADY BEEN ADMINISTERED
* MAGNESIUM SULFATE: * Dilute: 2g of magnesium sulfate in a 50mL bag of D5W * Administer over 10 minutes IV/IO by utilizing a 10 gtt set delivering 1 gtt/sec
54
PEDIATRIC: STABLE POLYMORPHIC V-TACH
* MAGNESIUM SULFATE: * Dilute: 40mg/kg in a 50mL bag of D5W * Administer over 10 minutes IV/IO by utilizing a 10 gtt set delivering 1 gtt/sec Max dose 2g
55
PEDIATRIC: UNSTABLE POLYMORPHIC V-TACH (AGE-APPROPRIATE HYPOTENSION)
* ETOMIDATE (consider for sedation): * 0.1mg/kg IV/IO, over 30 seconds, max single dose 6mg * May repeat 1x prn * DEFIBRILLATION: * 2j/kg, 4j/kg * If a PVT converts with defibrillation and later returns to a PVT, use the last successful energy setting and increase as needed
56
PEDIATRIC: IF UNSTABLE POLYMORPHIC V-TACH CONVERTS AFTER DEFIBRILLATION AND MAGNESIUM SULFATE HAS NOT ALREADY BEEN ADMINISTERED
* MAGNESIUM SULFATE: * Dilute: 40mg/kg in a 50mL bag of D5W * Administer over 10 minutes IV/IO by utilizing a 10 gtt set delivering 1 gtt/sec Max dose 2g
57
Left Ventricular Assist Devices - LVADs
Heart Pump
58
LVADs: HYPO-PERFUSION
* NORMAL SALINE: * 1L IV/IO, titrate to desired effect. Assess lung sounds and BP frequently May repeat 1x, prn
59
LVADs: UNRESPONSIVE PATIENTS
* ONLY perform chest compressions when the patient’s LVAD is not working and no other options exist to restart the LVAD * Evaluate unresponsive patients carefully for reversible causes by assessing: * A.E.I.O.U.-T.I.P.S. * H’s & T’s * CHECK BGL CHEST COMPRESSIONS: * Position hands to the right of the sternum to avoid LVAD dislodgement Contraindication: * DO NOT use the AutoPulse Precaution - Performing chest compressions risks rupturing of the ventricular wall leading, to fatal hemorrhage
60
LVADs: TRANSPORT
* Non-LVAD chief complaints should be transported according to the “Transport Destinations” protocol * If there are any questions regarding this, contact the EMS Captain and LVAD Coordinator * JFK MEDICAL CENTER LVAD COORDINATOR: * (561) 548-5823. Any LVAD issue should be transported to JFK Medical Center
61
Rhythms to be careful when synchronize cardiovert
Afib, Aflutter
62
Which med can be use prior to cardioversion if you suspect the underlying rhythm to be Afib or Aflutter
Adenosine 12mg

WPBfire EMS Protocol (13 decks)

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